Confidential Criminal History Check The Navarro Independent School District is required by Texas Education Code Chapter 22, Subchapter C, to review the criminal history of applicants, employees, independent contractors, student teachers, and volunteers. The information requested below is necessary to obtain criminal history record information and for fingerprinting purposes. Please Print all Information Name: ______________________________________________________________________________ Last (Legal name as shown on SS card) First Middle Social Security #: _________________________ Date of Birth: _________________________ Driver’s License or State ID: ________________ Phone #: _____________________________ State / Number Mailing Address: ______________________________________________________________________ Street City State Zip Sex: Male Female Ethnicity: Black Hispanic White/Other I understand the information I am providing about age, sex, and ethnicity will not be used to determine eligibility for employment but will be used solely for the purpose of obtaining criminal history record information. Applicant for: Professional Certified Teacher Administrative Support/Paraprofessional Substitute Teacher Substitute Paraprofessional (Secretary/Aide) Student Teacher/Observer Operations: Maintenance/Custodial Transportation Food Services Substitute Maintenance/Custodial/Food Services School District Volunteer: Campus/Classroom/Chaperone Other: ______________________ Please list campus or area: ___________________ (please list) Please read and sign the reverse side of this form. All incomplete forms will be returned and delay the process. Signature: __________________________________________ Date: ================================== CCH Report printed: Yes FOR DISTRICT USE ONLY ================================ No Initial: _______ Purpose: __________________ Approved/Hired Date: ________________________________ Destroy Date: __________________ Yes No __________ Initial: _________________ HR Forms Rev. 1/2012 NAVARRO INDEPENDENT SCHOOL DISTRICT P. O. Drawer 10 Geronimo, TX 78115  6450 N. State Hwy. 123 Seguin, TX 78155 830-372-1930 phone  830-372-1853 fax www.nisd.us An Equal Opportunity Employer NISD considers applicants for all positions without regard to race, color, national origin, age, religion, sex, marital status, veteran or military status, disability, or any other legally protected status. STUDENT TEACHER APPLICATION PERSONAL DATA Date of Application Name Last First Middle Initial Current address Street/Box City State ZIP Code Other mailing address _________________________ Primary Phone Email address Other name(s) that may appear on records (Used for certification, reference, and criminal history record checks) University currently attending: __________________________________________________________ Please attach an unofficial copy of your college transcript showing completed hours: Application will be considered incomplete until transcript is provided. Have you been employed by Navarro ISD in the past?  Yes  No If you answered yes, provide dates of employment EDUCATION / TRAINING Name and Location of Schools Attended Course of Study, Major and Minor Diploma, degree, certificate, or license ANTICIPATED CERTIFICATION -1- HR Forms 10/11 EMPLOYMENT EXPERIENCE - List experience beginning with most recent position Name and location Position/Title Dates Employed Reason for leaving REFERENCES Please list references the district can contact regarding your work history. Include all managers and supervisors who evaluated or supervised your performance at your last two employers. Full Name of Reference School District / Firm Name Mailing Address Position/Title Area Code, Phone No. GENERAL INFORMATION Have you ever been convicted of, pleaded guilty or no contest (nolo contendre) to, or received probation, suspension, or deferred adjudication for a felony, or any offense involving moral turpitude (including, but not limited to, theft, rape, murder, swindling, and indecency with a minor)?  Yes  No If yes, please state where, when, and the nature of the offense ______________________________________________________________________________ ______________________________________________________________________________ A Felony conviction is not an automatic disqualification of employment. The NISD will consider the nature, date, and relationship between the offense and the position for which you are applying. VERIFICATION This application becomes the property of the district. The district reserves the right to accept or reject it. I hereby affirm that all information provided in this application is true and accurate to the best of my knowledge and understand that any deliberate falsifications, misrepresentations, or omissions of facts may be grounds for rejection of my application or dismissal from subsequent employment. I authorize the references listed on the previous page to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all such parties from liability for any damage that may result from furnishing the same to you. I understand that the district is authorized by Texas Education Code §22.083 to obtain criminal history record information and fingerprinting results on applicants the district intends to employ. By completing the CHR form, I authorize the district to obtain and review CHR fingerprinting results. Signature -2- Date HR Forms 10/11 Confidential Criminal History Check The Navarro Independent School District is required by Texas Education Code Chapter 22, Subchapter C, to review the criminal history of applicants, employees, independent contractors, student teachers, and volunteers. The information requested below is necessary to obtain criminal history record information and for fingerprinting purposes. Please Print all Information Name: ______________________________________________________________________________ Last (Legal name as shown on SS card) First Middle Social Security #: _________________________ Date of Birth: ________________________ Driver’s License: _________________________ Phone #: _____________________________ State Number Mailing Address: ______________________________________________________________________ Street City State Zip Sex:  Male  Female Ethnicity:  Black  Hispanic  White/Other I understand the information I am providing about age, sex, and ethnicity will not be used to determine eligibility for employment but will be used solely for the purpose of obtaining criminal history record information. Applicant for:  Professional  Certified Teacher  Administrative Support/Paraprofessional  Substitute Teacher  Substitute Paraprofessional (Secretary/Aide)  Student Teacher/Observer Operations:  Maintenance/Custodial  Transportation  Food Services Substitute  Maintenance/Custodial/Food Services School District Volunteer:  Campus/Classroom/Chaperone  Other: ______________________ Please list campus or area: ___________________ (please list) School District Volunteer/Student Teacher: My signature below indicates that I have been notified that a Computerized Criminal History (CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on the personal information I have entered above. Because the name based information is not an exact search and only fingerprint record searches represent true identification of criminal history, the Navarro I.S.D., who conducting the criminal history check is not allowed to discuss any information obtained with me using this method; therefore the Navarro I.S.D. may offer me the opportunity to have a fingerprint search performed at my expense, to clear any misidentification based on name search, if the search provides a criminal report I know could not be mine. For employment purposes: I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety AFIS. I have been made aware that in order to complete this process I must have the correct fingerprinting (FAST) form from Navarro I.S.D., schedule the appointment, submit a full and complete set of my fingerprints and pay the fee of fingerprinting to L1 Enrollment Services Company. Once I have completed this process and the Navarro I.S.D. receives the data from DPS, the information on my fingerprint criminal history record may be discussed with me. Signature: __________________________________________ Date: ================================== CCH Report printed:  Yes FOR DISTRICT USE ONLY ================================  No Initial: _______ Purpose: __________________ Approved/Hired  Date: ________________________________ Destroy Date: __________________ -3- Yes  No __________ Initial: _________________ HR Forms 10/11